Provider Demographics
NPI:1700354933
Name:CHILDS, TYLER L (PA)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:L
Last Name:CHILDS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2860
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-2860
Mailing Address - Country:US
Mailing Address - Phone:501-315-4008
Mailing Address - Fax:501-315-3411
Practice Address - Street 1:1000 HWY 35 N STE 8
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-2353
Practice Address - Country:US
Practice Address - Phone:501-315-4008
Practice Address - Fax:501-315-3411
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA807363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical